End-of-life care in ICUs in East Asia: A comparison among China, Korea, and Japan

Objectives: To compare physicians' perceptions and practice of end-of-life care in the ICU in three East Asian countries cultures similarly rooted in Confucianism. Design: A structured and scenario-based survey of physicians who managed ICU patients from May 2012 to December 2012. Setting: ICUs in China, Korea, and Japan. Subjects: Specialists who are either intensivists or nonintensivist primary attending physicians in charge of patients (195 in China, 186 in Korea, 224 in Japan). Interventions: None. Measurements and Main Results: Country was independently associated with differences in the practice of limiting multiple forms of life-sustaining treatments on multivariable generalized linear model analysis. Chinese respondents were least likely to apply do-not-resuscitate orders, even if they existed (p < 0.001). Japanese respondents were most likely to practice do not resuscitate for terminally ill patients during cardiac arrest, even when no such prior order existed (p < 0.001). Korean respondents' attitudes were in between those of Chinese and Japanese respondents as far as withdrawing total parenteral nutrition, antibiotics, dialysis, and suctioning was concerned. Chinese respondents were most uncomfortable discussing end-of-life care issues with patients, while Japanese respondents were least uncomfortable (p < 0.001). Chinese respondents were more likely to consider financial burden when deciding on limiting life-sustaining treatment (p < 0.001). Japanese respondents felt least exposed to personal legal risks when limiting life-sustaining treatment (p < 0.001), and the Korean respondents most wanted legislation to guide this issue (p < 0.001). The respondents' gender, religion, clinical experience, and primary specialty were also independently associated with the different perceptions of end-of-life care. Conclusions: Despite similarities in cultures and a common emphasis on the role of family, differences exist in physician perceptions and practices of end-of-life ICU care in China, Korea, and Japan. These findings may be due to differences in the degree of Westernization, national healthcare systems, economic status, and legal climate.